Healthcare Provider Details

I. General information

NPI: 1285089144
Provider Name (Legal Business Name): BRANT PARKINSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1327 E 17TH ST
IDAHO FALLS ID
83404-6235
US

IV. Provider business mailing address

1327 E 17TH ST
IDAHO FALLS ID
83404-6235
US

V. Phone/Fax

Practice location:
  • Phone: 208-538-3122
  • Fax: 208-561-2998
Mailing address:
  • Phone: 208-538-3122
  • Fax: 208-561-2998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1369
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: